ingrowing toenail

; IGTN; onychocryptosis; OC perforation of the epidermis and dermis of the nail sulcus by a spike, shoulder or serrated edge of the adjacent nail plate; most commonly affects the hallux nail, especially in adolescent boys with hyperhidrosis; the degree of nail penetration increases over time (days to weeks) inducing further local swelling; involved soft tissues are inflamed (very tender, red and swollen), and may become infected (paronychia); an area of partially epithelialized hypergranulation tissue (i.e. a pyogenic granuloma) overlies the ingrown area of nail in long-standing cases; treatment includes excision of the nail spike (under local anaesthetic), partial avulsion of the nail plate (under local anaesthetic) with ablation of the associated nail matrix to prevent plate regrowth, together with treatment of the underlying cause (e.g. advice on nail cutting, control of hyperhidrosis, provision of antipronatory orthoses) and shoe advice (including correct fitting [ seeTable 1] and use of laces); Table 2 and see Table M2

Table 1: Presentations and treatment approaches for ingrown toenail

Stage

Characteristics

I

Patient complains of pain in the nail sulcus, especially in shoesMinimal visual signs of IGTN (slight swelling, slight redness)• May resolve with local removal of nail spike or small sliver of the outer margin of the nail plate and gentle packing of the sulcus with sterile cotton wool

II

Patient complains of acute painVisual signs of local inflammation: redness, swelling; hyperhidrosisHypergranulation arising from affected nail sulcusSeropurulent (smelly) discharge• May resolve with local removal of nail spike or small sliver of nail plate under local anaesthetic, together with gentle packing of the sulcus with sterile cotton wool• May require excision of the section of the nail plate, together with gentle packing of the sulcus with sterile cotton wool, but there is a high risk that the problem will recur as the nail plate regrows• May require excision of the section of the nail plate, together with ablation of the exposed pocket of matrix (by application of phenol or potassium hydroxide or electrosurgery or surgical excision); the hypergranulation tissue may be excised, or left in situ where it will gradually atrophy over the next 2 weeks; there is an approximately 5% risk of regrowth of the excised section of nail plate

The means that retains the foot within the shoe: laces, buckle and bar, T-bar strap, Velcro strapsThe foot should be well seated into the heel part of the shoe, with the plantar aspect inclined upwards at 45° to the ground surface before the retain medium is closed around the foot

Close-fitting medial and lateral quarters

The close fit of the shoe quarters around the tarsus of the foot complements the retaining mechanism, and reduces frictional forces around the heelIn a well-fitting shoe there will be no mediolateral or anterior-posterior drift, or slip of the foot against the heel counter of the foot during gait

Adequate toe box

The forepart of the shoe should be wide and deep enough to allow normal toe function throughout gait, and should coincide with the natural outline of the forefootThe tips of the toes should not be in contact with the toe end of the shoe, and the toe puff should not exert pressure on the dorsal nail platesThe toes will contact the inner of the toe box if the shoe is too large or too small for the foot

Correct length

Shoes that are too short or too long predispose to digital and nail lesions, toe deformity and reduced foot functionThe MTPJs should coincide with the maximum width of the forepart of the shoe

Correct width

The correct width of the shoe will allow the toes to lie straight and unrestricted and in their normal relationship during gaitThe widest part of the shoe should coincide with the transverse width of the foot across the MTPJ parabolaDeep creases across the forefoot upper indicate a shoe that is too narrow for the foot

Adequate heel seat

The heel seat accommodates the heel of the footA too-narrow heel seat causes the formation of a ridge of callosity at the heel periphery

Appropriate heel height

The vertical height of the heel of the shoeThe weight of the body is transferred to the forefoot, the lumbar spine is extended and the stride length is reduced if a shoe with a heel height of >5 cm is wornThe greater the height of the heel, the greater the instability of the foot and the greater the chance of trauma (inversion sprain, avulsion fracture)

Broad heel base

The outsole of the heel should at least match the width of the rear part of the shoe in order to ensure maximum stability in the normal footThe narrower the heel contact area, the greater the force transferred to the body during gait at heel strike, and the greater the chance of trauma (inversion sprain, avulsion fracture)

Leather upper

Leather is supple and strong, and will stretch to some extent to accommodate toe deformityLeather is permeable, and will absorb sweat

That's why you had to be subjected to the ramblings of a mad man and his ingrowing toenail (two words chump), instead of your usual weekly slice of hilarity and well-thought out, carefully constructed prose.

They include 38-year-old Liz White who caught MRSA while giving birth by caesarean, Vladimir Howard, 78, who was treated for an ingrowing toenail and ended up having a leg amputated and Alfred Flynn - one of the first to die from the disease almost 20 years ago.

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